Analysis Failure of the Raw Water Cooling System After the vessel was recovered, it was discovered that one of the two 28.5mm, wire-reinforced rubber hoses on the discharge side of the raw water cooling system had parted. This failure was located in the section between the heat riser and the through-hull fitting at the side of the vessel, within the engine compartment. The hose parted where two lengths of hose of the same diameter had been joined with a metal connector. Examination of this connector revealed that, in place of a straight connector, a reducer had been used. One end of this reducer matched the 28.5mm inside diameter of the rubber hose, while the other end was 25.4mm in diameter. This smaller diameter had been built up to match the 28.5mm inside diameter of the hose by the application of plastic electrician's tape. Two hose clamps had then been secured over each hose end at the reducer. The raw cooling water, its temperature raised by heat drawn from the engine, warmed the electrician's tape and softened its adhesive. The wire reinforcing within the rubber hose limited the ability of the hose clamps to compress the hose against the reducer. The pressure of the cooling water, as supplied by the circulating pump, was sufficient to elongate the warmed adhesive of the electrician's tape until the connection failed and the hose parted (seePhoto3). Photo3. Electrician's tape protruding from failed joint in engine cooling hose The engine's raw water circulation pump continued to supply cooling water to the system. Where the hose had parted, that water now flowed into the vessel's bilges instead of overboard. Because this hose failure occurred during darkness, it is unlikely that the operator would have been able to observe that the cooling water discharge was now reduced to a single stream. The accumulation of water in the bilges would have served to trim the vessel by the stern. A vessel's change of trim can often be detected when referenced to the horizon. This, however, would be more difficult to detect during darkness. The noise generated by the engine would most probably have obscured the sound of the accumulating water moving within the vessel - an additional warning that a dangerous situation had developed. The strain astern on the towing post caused by the load of the tow line, coupled with the force of the propeller driving the vessel ahead, would have quickly resulted in the stern sinking even lower in the water. This would have allowed the cooling water accumulating in the bilges to shift aft, further exacerbating the situation. The rate at which the engine's raw water circulating pump supplies seawater is proportional to the operating speed of the engine. Information supplied by the engine's manufacturer indicates that the pump fitted on the BruceBrown had a maximum flow rate of 173litres per minute (L/min.) with the engine operating at a maximum of 2100RPM. With the engine operating at an estimated service speed of 1700RPM, it is reasonable to assume a supply rate of 140L/min., supplying 70L/min. to each discharge hose. It has been determined by measurement that the volume of the vessel's bilge in way of the engine is approximately 3.5m3, and seawater filling that space would have a mass density of approximately 3.6tonnes. By calculation, at 70L/ min., the bilge would fill in 50minutes. However, given the low freeboard of the vessel, it can be estimated that the addition of approximately 1.8metric tons of seawater would cause the stern to become submerged to the point where seawater would downflood into the vessel's after well deck and eventually flow forward over the partial transverse bulkhead into the accommodation space. Without corrective action, the vessel would capsize. By calculation, this sequence would take approximately 25minutes from the time of the hose failure. Complexity of Regulatory Safety Requirements Regulatory compliance for small non-passenger vessels of 15gross tons and under is based on enforcement by owners. The application of the self-enforcement principle presupposes that the owner/operator has an in-depth knowledge of marine legislation and the operational environment, and has sufficient resources and appropriate skills to educate the operator or crew. This principle may work well in large corporations; however, few operations within the small vessel sector engaged in carrying passengers, fishing activity, or other commercial activity have a scale of operation sufficiently large to allocate resources to meet these objectives. The majority of the over 30000small vessels operating in Canada are operated by small companies, or individuals who may own and operate a vessel with a few employees. There is no requirement for the owner/operator to possess an in-depth knowledge of marine regulations or for the operator to possess academic qualifications, nor is a competency test required before a person can engage in marine activities. As the regulations are involved and require knowledgeable interpretation and application, they may not be readily understood by those who must apply them. Simplifying regulations in the small vessel industry is central to supporting self-enforcement. This need has been recognized by Transport Canada, which in other marine sectors has published guides and manuals to assist owners or operators to operate their vessels safely.5 Until2003, there was no such publication for the small passenger or non-pleasure vessel sector.6 The difficulty in interpreting and applying current marine legislation calls into question the practicality of self-enforcement as a compliance tool for small vessels. The issue of self-enforcement of complex legislation and regulations has been discussed in the 1996TSB report on an occurrence involving S.S.Brothers (TSBReportM96M0144) and the 2001TSB report on an occurrence involving WascaII(TSBReportM01W0116). In the report involving S.S.Brothers, the Board recommended that legislation be presented in a manner readily understood by those to whom it applies.7 While the recommendation addressed provincial labour legislation as it applies to fishing vessel safety, the principle equally applies to any legislation that uses self-enforcement as a means of enforcement. To address this deficiency, Transport Canada has extended the application of the Interim Small Vessel Monitoring and Inspection Program to cover all small commercial vessels. Under the program, the first inspection requirement will help ensure that existing vessels meet the regulatory requirement and that they are safe to operate. It is envisioned that this will provide owners/operators with the appropriate information and guidance to operate their vessels safely. Operator Certification and Safety A minimum level of skill and knowledge is required of those who operate an automobile or aircraft, whether for commercial or recreational purposes. In the marine environment, there is no such proficiency or competency requirement for operators of small commercial vessels, whether these vessels are used for carrying passengers, fishing activities, or other commercial operations.8 However, there is a proficiency requirement for some pleasure craft operators, which will apply to all operators by September2009.9 The need for formal training of vessel operators has been recognized by Transport Canada, as well as by the Canadian Coast Guard. Crewing Regulations for commercial vessels and the Competency of Operators of Pleasure Craft Regulations are intended to address this need. Nevertheless, operators of small vessels, such as passenger vessels of 5gross tons and under that do not carry more than 12passengers, small commercial vessels of 15gross tons and under, and fishing vessels 60gross tons and under are not required to demonstrate a minimum level of knowledge to operate their vessels. As a result, many small commercial vessel operators continue to operate in Canadian waters without demonstrating a minimum knowledge. The lack of a requirement for operators to demonstrate their qualifications and knowledge has been identified as a finding in a number of TSB reports. To address this deficiency, Transport Canada, in consultation with stakeholders, is considering Small Vessel Operator Proficiency requirements that will apply to all commercial vessels currently excluded from the regulations. The new proficiency requirements are being examined as part of the reform of the Crewing Regulationsand Marine Certification Regulations. Drowning TSB statistics record 70marine fatalities for the period 1992-2001, where crew either fell overboard or were carried overboard. An additional 26fatalities occurred during the same period, a portion of which can be attributed to vessels that foundered or capsized. In British Columbia, Workers' Compensation Board statistics in the fishing industry for the period 1991-2001 record 50drowning fatalities. Many of these fatalities can be attributed to sudden immersion in cold water (i.e.below15C). In light of the number of cold-water fatalities, Dr.C.J.Brooks prepared the report Survival in Cold Waters (TP13822) for Transport Canada. This report defines the four clear stages of immersion in which death can occur: cold shock (kills within 3-5minutes after immersion); swimming failure (kills within 30minutes after immersion); hypothermia (kills after 30minutes of immersion); and post-rescue collapse (kills at the point of rescue or up to several hours afterward). The report underscores the fact that entry into water below 15C, even with the aid of flotation, sharply increases the risk of death and should be avoided. Even a lifejacket, if not properly worn or without a spray hood, does not guarantee the victim protection from drowning. Among the report's recommendations are that Transport Canada introduce new regulations for the carriage of liferafts on vessels sailing on waters 15C and below, and approval of modern inflatable lifejackets in view of the fact that flotation devices are only of benefit when they are worn. Small commercial vessels vary in size. In addition, they may be of open construction and may be used in a wide range of activities such as whale-watching, where they carry passengers, and log salvage, where they are used to tow logs. The carriage of an inflatable liferaft is not always practical. Hence, personal life-saving equipment that provides both flotation and thermal protection capabilities is essential to maximize survival time for persons in the water. Bearing in mind the need to overcome the most critical phase of cold shock, it is essential that the personal life-saving equipment has the capability to turn the person face-up in the water. A review of available equipment indicates that full-length PFDs equipped with flotation collars provide these capabilities. The two crew members aboard the BruceBrown were both wearing PFDs, yet the death of one was attributed to hypothermia and the other to drowning. The accident took place close to shore but during darkness. The vessel capsized so rapidly that a radio distress call could not be made and there was little time to prepare for evacuation. The dock under tow would have made a suitable rescue platform; however, without a means of boarding, the cold water rapidly demobilized the victims to the point where this was not possible. Marine Emergency Duties (MED) Training Under the Canada Shipping Act, Crewing Regulations, section21, all marine crew members, including those on fishing vessels, are required to complete MED training within six months of joining a vessel's crew. MED training has been required on large commercial vessels since the late-1970s. This training requirement was extended to all small commercial vessels, including small fishing vessels, by Transport Canada in1997, following findings by the TSB that most marine accidents resulting in loss of life occur on small fishing vessels. The department agreed that a formal training regime was required to create a higher level of safety awareness within the fishing community and to help reduce the number of fatalities. The training requirement for small commercial vessels applies to crew members on: fishing vessels under 150tons; and non-passenger vessels and passenger vessels under 150 tons, with unberthed accommodations only, operating on Minor Waters and Home-Trade voyages, ClassIV. The MEDA-3 and MEDA-4 courses were developed for crew members on vessels operating no more than 20miles from shore. These courses provide basic safety-at-sea awareness and are tailored specifically for crew members of smaller vessels and for the environment of near-shore operations. Transport Canada is currently working with approved safety training providers and industry associations to enhance awareness among mariners about the MED training requirement and to make the training available in remote areas. Mariners who do not yet have training available in their area of operation were required to demonstrate, before 30July2003, or within a reasonable period after the training becomes available in their area, that they have registered to take the appropriate MEDcourse. Transport Canada will enforce the requirement without exception after 01April2007. An improper hose connection on the discharge side of the engine's raw water cooling system failed. This failure allowed seawater, supplied by the engine's raw water pump, to quickly fill the vessel's bilges and engine compartment at the after end of the vessel. The vessel's bilge pump was rigged for manual operation and was not fitted with a bilge high level alarm, either visual or audible, nor was this a mandatory requirement. The vessel was not required to carry an emergency position indicating radio beacon (EPIRB), nor did it do so, and the rapidity of the capsize precluded any broadcast of a VHF radio distress call to alert the authority. The personal flotation devices used by the crew of the vessel did not provide adequate flotation and thermal protection capabilities. The vessel was not equipped with an inflatable liferaft, nor was it required to by regulations.Findings as to Causes and Contributing Factors An improper hose connection on the discharge side of the engine's raw water cooling system failed. This failure allowed seawater, supplied by the engine's raw water pump, to quickly fill the vessel's bilges and engine compartment at the after end of the vessel. The vessel's bilge pump was rigged for manual operation and was not fitted with a bilge high level alarm, either visual or audible, nor was this a mandatory requirement. The vessel was not required to carry an emergency position indicating radio beacon (EPIRB), nor did it do so, and the rapidity of the capsize precluded any broadcast of a VHF radio distress call to alert the authority. The personal flotation devices used by the crew of the vessel did not provide adequate flotation and thermal protection capabilities. The vessel was not equipped with an inflatable liferaft, nor was it required to by regulations. The owner/operator converted the vessel for commercial log-salvage operations without informing Transport Canada. Due to the length of the tow, the operator was required to communicate with the Marine Communications and Traffic Services, but did not do so. Transport Canada has developed Marine Emergency Duties (MED) training courses, MEDA-3 and MEDA-4, specifically for crew members on vessels operating no more than 20miles from shore to provide basic safety-at-sea awareness training. Neither crew member had taken this training.Findings as to Risk The owner/operator converted the vessel for commercial log-salvage operations without informing Transport Canada. Due to the length of the tow, the operator was required to communicate with the Marine Communications and Traffic Services, but did not do so. Transport Canada has developed Marine Emergency Duties (MED) training courses, MEDA-3 and MEDA-4, specifically for crew members on vessels operating no more than 20miles from shore to provide basic safety-at-sea awareness training. Neither crew member had taken this training. The object under tow was not lit. The vessel was not appropriately marked with the vessel license number, which delayed identification. There are no marine-specific criteria for the issue of a log salvage licence. The vessel was fitted with a VHF radio, but the operator was not trained or certified in the use of the VHF radio as required by regulations.Other Findings The object under tow was not lit. The vessel was not appropriately marked with the vessel license number, which delayed identification. There are no marine-specific criteria for the issue of a log salvage licence. The vessel was fitted with a VHF radio, but the operator was not trained or certified in the use of the VHF radio as required by regulations. In August 2002, Transport Canada issued Ship Safety Bulletin No.09/2002, Bilge Pumping Systems: Early Detection Saves Lives, to communicate to the industry the importance of bilge pumping systems and the early detection of any leakage into the hull compartments of any vessel. In 2004, Transport Canada issued the Small Commercial Vessel Safety Guide (TP14070). Transport Canada is in the process of incorporating the Construction Standards for Small Vessels (TP1332)as a Standard, by reference, into the Small Vessel Regulations. When this is done, the bilge high level alarm will become mandatory.Safety Action In August 2002, Transport Canada issued Ship Safety Bulletin No.09/2002, Bilge Pumping Systems: Early Detection Saves Lives, to communicate to the industry the importance of bilge pumping systems and the early detection of any leakage into the hull compartments of any vessel. In 2004, Transport Canada issued the Small Commercial Vessel Safety Guide (TP14070). Transport Canada is in the process of incorporating the Construction Standards for Small Vessels (TP1332)as a Standard, by reference, into the Small Vessel Regulations. When this is done, the bilge high level alarm will become mandatory.